Malingering in the medical setting

Malingering in Adolescent Psychiatry: A Case Report of Fabricated Symptoms to Avoid Legal Consequences

Malingering is characterized by the deliberate fabrication and/or exaggeration of symptoms for secondary gain, posing a diagnostic challenge in healthcare settings. In this report, we present a 15-year-old male with a history of psychiatric disorders who attempted suicide to avoid legal sentencing, subsequently developing a stutter following an altercation with another patient. Despite initial concern for a concussion, further evaluation revealed malingering as the underlying motive. This case highlights the importance of identifying malingering in adolescents, which calls for a careful approach and thorough assessment for it to be distinguished from an authentic illness. Early identification of malingering optimizes resource allocation and ensures appropriate care for patients who have genuine medical needs.

Temporal model for central sensitization: A hypothesis for mechanism and treatment using systemic manual therapy, a focused review

The purpose of this focused review is to develop a consolidated hypothesis as to the causes and mechanisms of central sensitization and a related model for a treatment approach using Systemic Manual Therapy (SMT). The key to understanding central sensitization is a firm grasp on structure and function of the Locus-coeruleus noradrenaline system (LC-NA). This system uses an elaborate switching mechanism to control the level and rate of activation of multiple systems. This review evaluates the mechanisms and temporal relationships behind four components: salient stimuli, threat coding, aberrant afferent input, and oxidative stress. The five-stage temporal model for central sensitization includes phasic activation of the LC-NA system, salient stimuli, threat coding of salient stimuli, central sensitization, and neural degeneration. The three components of treatment include temporarily reducing afferent visceral input, shifting humoral inflammatory activity away from the brain and outside the body, and reducing oxidative stress by making oxygenated blood more available around the LC and other stressed areas in the brain. The SMT protocols that could help in reduction of visceral afferent input are GUOU, Barral and LAUG. Protocols that should shift humoral inflammatory activity away from the brain or completely out of the body include UD and DCS. One protocol that can potentially reduce oxidative stress by making oxygenated blood more available around the LC is CCCV. Future research and hypothesis-testing strategies as well as limitations are further discussed.

Fibromyalgia: epidemiology and risk factors, a population-based case-control study in Damascus, Syria

Background

Fibromyalgia is a chronic disease with a high burden. We aim to be the first to investigate the prevalence of fibromyalgia (FM) in Syria and assess its risk factors.

Methods

A self-reported questionnaire was distributed to the public to identify fibromyalgia patients using the American College of Rheumatology (ACR) 2010 modified criteria. Identified cases were matched using age with controls free from rheumatic disorders that were randomly sampled from the same population.

Results

Out of 2966 participants, 350 (11.8%) satisfied the diagnostic criteria. Of these, only 29 (8.2%) were previously diagnosed by a physician, 239 (68.3%) were females, and 69 (19.71%) were diagnosed with depression. Female sex (OR = 1.31), diagnosis of major depressive disorder (OR = 2.62), irritable bowel syndrome (OR = 1.8), and Restless legs syndrome (OR = 1.72) were associated with a higher likelihood of fibromyalgia.

Conclusion

Our study revealed one of the highest prevalence rates of fibromyalgia ever reported in the general population. Efforts must be intensified to increase awareness about this disease in Syrian society as well as among healthcare providers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41927-022-00294-8.

Factitious Gastrointestinal Bleeding: A Case Series and Review

Factitious gastrointestinal bleeding (GIB) is a manifestation of factitious disorder (FD) wherein patients feign GIB in the absence of external gain. As it can be a challenging diagnosis to make, factitious GIB often leads to multiple tests, exposure to contrast agents and radiation, invasive endoscopic and surgical procedures, an increased risk of iatrogenic complications, and increased healthcare costs. Patients who feign GIB often demonstrate characteristic behaviors that may go unnoticed unless they are explicitly addressed. We report a series of patients admitted to our institution for further evaluation of obscure overt GIB with an eventual diagnosis of factitious GIB and review of the epidemiology and development of FD, a diagnostic approach to factitious GIB, and current management strategies.

Suicide and Self-Harm Outcomes Among Psychiatric Emergency Service Patients Diagnosed As Malingering

BACKGROUND

Malingering is a common and challenging clinical presentation in emergency departments (EDs).

OBJECTIVE

This study describes characteristics and outcomes among patients diagnosed as malingering in a psychiatric emergency service.

METHODS

Index psychiatric ED encounters were identified for all adult patients seen during a 27-month period. Mortality data were obtained for patients from the state public health authority, and repeat ED visits for self-harm were obtained from the state hospital association. Patients with a diagnosis of malingering were compared with those without a malingering diagnosis using correlative statistics and multivariable analyses.

RESULTS

Of 4710 encounters analyzed, 236 (5%) had a malingering diagnosis. No patients diagnosed as malingering died of suicide within 365 days of discharge, compared with 16 (0.4%) nonmalingering patients. Self-harm outcomes were available for 2689 encounters; 129 (5%) had a malingering diagnosis. Malingering was significantly associated with a repeat ED visit for self-harm within 365 days in multivariable analyses (adjusted odds ratio 2.52; 95% confidence interval 1.35-4.70); p < 0.01).

CONCLUSIONS

No psychiatric emergency service patients diagnosed as malingering died by suicide after discharge. New clinical approaches must balance malingering patients' apparent low suicide risk with their other substantial comorbidities and risk for self-harm.

Consistency does not aid detection of feigned symptoms, overreporting does: Two explorative studies on symptom stability among truth tellers and feigners

Practitioners always want to exclude the possibility that a patient is feigning symptoms. Some experts have suggested that an inconsistent symptom presentation across time (i.e., intraindividual variability) is indicative of feigning. We investigated how individuals with genuine pain-related symptoms (truth tellers; Study 1 n = 32; Study 2 n = 48) and people feigning such complaints (feigners; Study 1 n = 32; Study 2 n = 28) rated the intensity of their symptoms across a 5-day period. In both studies, feigners reported on all 5 days significantly higher symptom intensities than people with genuine complaints, but the two groups did not differ with regard to symptom (in)consistency. Thus, persistently inflated, rather than inconsistent, reports of symptom intensity over time are suggestive of feigning. The implications and limitations of our work are discussed.

Cues for feigning screening in whiplash associated disorders

The objective of this work is to evaluate the ability of a series of possible feigning indicators, extracted from relevant literature in the field, to discriminate between clinical patients with genuine symptomatology and instructed malingerers. A sample of 273 participants divided into two groups was used for this study: 153 whiplash associated disorder patients who were evaluated at a multidisciplinary medical center in the region of Murcia (Spain), between December 2017 and March 2019 and 120 healthy controls with malingering instructions, students of the Faculty of Medicine of the University of Murcia. In order for researchers to evaluate the indicators included in the study, a 22-step checklist (CDS) was developed, consisting of 22 criteria divided into 5 dimensions. Our results show that 18 of 22 indicators could discriminate between groups. Dimension 2 "Attitude toward the situation of illness" presented the greatest capacity for discrimination. In general terms, malingerers express a much more negative experience of the condition than the clinical patients.

Validity Assessment in Traumatic Brain Injury Impairment and Disability Evaluations

This article provides an overview of validity assessment in persons with traumatic brain injury including evaluation caveats. Specific discussion is provided on post-concussive disorders, malingering, examination techniques to assess for validity, response bias, effort and non-organic/functional presentations. Examinee and examiner biases issues will also be explored. Discussion is also provided regarding judicial trends in limiting examiner scope of testing and/or testimony, and risk of liability when providing expert witness opinions on validity of examinee presentations. The hope is to encourage physiatrists to become more aware and skilled in validity assessment given its importance in differential diagnosis of impairment following traumatic brain injury.

The therapeutic discharge: An approach to dealing with deceptive patients

OBJECTIVE

Patients with factitious disorder or malingering behaviors pose particular problems in acute care settings. We sought to describe a manner to effectively discharge these patients and keep further harm, iatrogenic or otherwise, from being inflicted.

METHOD

Once an indication has been identified, the therapeutic discharge can be carried out in a stepwise fashion, resulting in a safe discharge. We outlined how to prepare for, and execute, the therapeutic discharge, along with preemptive consideration of complications that may arise.

RESULTS

Consequences for the patient, physicians, and larger healthcare system are considered.

CONCLUSION

The therapeutic discharge is a safe and effective procedure for patients with deception syndromes in acute care settings. Carrying it out is a necessary element of psychiatric residency and psychosomatic medicine fellowship training.

Can individuals with schizophrenia be instructed to deliberately feign memory deficits?

INTRODUCTION

Neuropsychological tests are increasingly applied in research studies and clinical practice in psychiatry. In this context, the detection of poor effort is crucial to adequately interpret data. We measured schizophrenia patients' performance on a memory test designed to detect excessive malingering (the "21-Item Test"), before examining whether a second group of schizophrenia patients would excessively malinger on this test when given an incentive to feign memory impairment.

METHODS

Two independent studies including respectively 49 schizophrenia patients and 100 controls (study 1) and 25 schizophrenia patients and 25 controls (study 2) were conducted. In study 1, participants were asked to complete the 21-Item Test to the best of their ability. In study 2, participants were given a hypothetical scenario in which having a memory impairment would be financially advantageous for them, before completing the 21-Item Test.

RESULTS

In study 1, no participant scored at levels indicative of excessive malingering. In study 2, 84% of controls but only 36% of patients scored at excessive levels of malingering, and these patients had higher executive functioning than patients who did not excessively malinger, although it should be noted that a significantly greater proportion of patients excessively malingered in study 2 compared to study 1.

CONCLUSIONS

These results indicate that schizophrenia patients do not normally feign excessive memory impairment during psychological testing. Furthermore, they are less able and/or less inclined to excessively malinger than controls in situations where a memory impairment would be advantageous, perhaps indicating a better ability to malinger without detection. Potential clinical implications are discussed.

Malingering psychosis: guidelines for assessment and management

PURPOSE

The purposes of this paper are to (a) identify theoretical underpinnings of malingering, (b) to discuss interview and intervention techniques based on pertinent literature, and (c) to offer an organized mnemonic to help clinicians easily identify possible malingered psychosis presentations.

CONCLUSION

Detecting the malingering of psychotic symptoms is a challenging task for Advanced Practice Psychiatric Nurses. Diagnosing a patient of malingering requires caution on the clinician's part.

PRACTICE IMPLICATIONS

A thorough understanding of potential signs of malingering vs. genuine psychosis is needed as well as knowledge of legal ramifications.

A known-groups evaluation of the response bias scale in a neuropsychological setting

We evaluated the Minnesota Multiphasic Personality Inventory-Second Edition (MMPI-2) Response Bias Scale (RBS). Archival data from 83 individuals who were referred for neuropsychological assessment with no formal diagnosis (n = 10), following a known or suspected traumatic brain injury (n = 36), with a psychiatric diagnosis (n = 20), or with a history of both trauma and a psychiatric condition (n = 17) were retrieved. The criteria for malingered neurocognitive dysfunction (MNCD) were applied, and two groups of participants were formed: poor effort (n = 15) and genuine responders (n = 68). Consistent with previous studies, the difference in scores between groups was greatest for the RBS (d = 2.44), followed by two established MMPI-2 validity scales, F (d = 0.25) and K (d = 0.23), and strong significant correlations were found between RBS and F (rs = .48) and RBS and K (r = -.41). When MNCD group membership was predicted using logistic regression, the RBS failed to add incrementally to F. In a separate regression to predict group membership, K added significantly to the RBS. Receiver-operating curve analysis revealed a nonsignificant area under the curve statistic, and at the ideal cutoff in this sample of >12, specificity was moderate (.79), sensitivity was low (.47), and positive and negative predictive power values at a 13% base rate were .25 and .91, respectively. Although the results of this study require replication because of a number of limitations, this study has made an important first attempt to report RBS classification accuracy statistics for predicting poor effort at a range of base rates.

Malingering? No evidence in a predominantly Hispanic workers' compensation population with chronic pain

Providers suspect malingering when patients seek compensation for injury or when pain is unconfirmed via objective evidence, judged disproportionate to the cause, or recalcitrant to treatment. Suspicions or claims of malingering may prejudice treatment or reimbursement decisions. The purpose of this archival study was to identify malingering in a predominantly Hispanic workers' compensation population seeking treatment for pain. We used a correlational archival research design to collect data from the medical records of 91 patients treated over a 10-year period in a specialty clinic. Inclusion criteria included individuals with psychologic evaluation for persistent pain that affected function. Using a priori power analysis for a medium effect size, power of .80, and alpha of .05, data from 85 medical records were necessary to meet correlational significance. The study sample reflects the ethnicity, educational level, and socioeconomic status of the larger U.S.-Mexico border community. The majority (93%) had workers' compensation and about one-third had active litigation. No one was diagnosed with malingering or pain disorder with primarily psychologic origins. Depression coexisted with chronic pain, and patients reported serious impairment in physical, occupational, and social function an average of 5 years after the onset of chronic pain. However, the vast majority of patients returned to work. In our experience, there is no place for the labeling and resultant stigma of malingering in chronic pain sufferers.

Simulação em lombalgia: diagnóstico e prevalência

OBJETIVO: Fazer uma revisão da literatura para diagnóstico de simulação em lombalgia e avaliar sua prevalência nos pacientes que pleiteiam benefício previdenciário. MÉTODOS: Foram avaliados 100 pacientes com lombalgia referida, divididos em dois grupos de 50; no grupo I os pacientes requisitaram o relatório médico a fim de obter benefício, no grupo II os pacientes visavam apenas tratamento. Foram considerados simuladores os pacientes que apresentavam dois sinais positivos, dos três avaliados: dor lombar à compressão axial crânio, dor lombar à rotação em bloco do tronco e diferença em sintomatologia na elevação da perna em posição sentado e supina. RESULTADOS: No grupo I a porcentagem de simuladores foi 72%, no grupo II 18%, não houve diferença significativa com relação a idade ou sexo dos pacientes. DISCUSSÃO: Apesar de haver vários sinais e sintomas para avaliar simulação a maioria dos médicos os desconhece, não fazendo uma avaliação adequada dos pacientes com lombalgia referida, contribuindo assim para o inchaço do sistema previdenciário. CONCLUSÃO: Há uma elevada incidência de simuladores entre os pacientes que requerem relatório médico a fim de conseguir benefício previdenciário. Nivel de Evidência II, prospectivo comparativo.

Disability evaluation of the pain : the present and prospect in Korea

OBJECTIVE

Pain has long been regarded as a subjective symptom. Recently, however, some regard a type of intractable chronic pain as a disease. Furthermore, chronic persistent pain becomes a cause of permanent impairment (PI). In 6th edition, the American Medical Association (AMA) Guides has rated the pain as a PI. In Korea, pain has been already been rated as a PI. Here, we examined the present status and the prospect of disability evaluation for the pain in Korea.

METHODS

Pain can be rated as a PI by the Workmen's Compensation Insurance Act (WCIA) and Patriots and Veterans Welfare Corporation Act (PVWCA) in Korea. We examined the definition, diagnostic criteria and grades of the pain related disability (PRD) in these two acts. We also examined legal judgments, which were made in 2005 for patients with severe pain. We also compared the acts and the judgments to the criteria of the 6th AMA Guides.

RESULTS

The PRD can be rated as one of the 4 grades according to the WCIA. The provisions of the law do not limit the pain only for the complex regional pain syndrome (CRPS). The PRD can be rated as one of the 3 grades by the PVWCA. If there were objective signs such as osteoporosis, joint contracture and muscle atrophy corresponding to the CRPS, the grade is rated as 6. When the pain always interferes with one's job except easy work, the grade is rated as high as 5. In Korea, judicial precedents dealt the pain as a permanent disability in 2005.

CONCLUSION

Although there were no objective criteria for evaluation of the PRD, pain has been already rated as a PI by the laws or judicial precedents, in Korea. Thus, we should regulate the Korean criteria of PRD like the AMA 6th edition. We also should develop the objective tools for evaluation of the PRD near in future.